520.4 AUTHORIZATION FOR RELEASE OF STUDENT RECORDS

The undersigned hereby authorizes the ___________________ Community School District and any of its agents to release official student records of:

(Legal Name of Student)

(Date of Birth)

(Name of Last School Attended)

(Dates of Attendance)

The undersigned specifically authorizes the release of the following official student records of the above student: (If no records are specified, the undersigned authorized the release of all student records of the above student.)

___________________________________________________________________________

___________________________________________________________________________

The reason for the authorization:__________________________________________________

____________________________________________________________________________

Copies of the records shall be furnished to the following (check all that apply):

(  )  the undersigned

(  )  the student

(  )  other (please specify:__________________________________________________)

The undersigned has the following relationship to the student: __________________________

___________________________________            ___________________________________

(Signature)                                                                  (Address)

___________________________________            ___________________________________

(Printed Name)                                                          (City, State, Zip Code)

                                                                                  ___________________________________

                                                                                  (Phone Number)